Prospective randomised single-blind controlled trial of glacial acetic acid versus glacial acetic acid, neomycin sulphate and dexamethasone spray in otitis externa and infected mastoid cavities

Antibiotics versus non-antibiotic treatments for acute otitis externa: A systematic review and meta-analysis

BACKGROUND

Otitis externa is a condition causing inflammation of the outer ear canal, which presents with itching, discharge and pain. Most cases of acute otitis externa are caused by bacterial infection and are thus treated with antibiotics. This systematic review and meta-analysis of randomised controlled trials aims to assess the effectiveness of topical non-antibiotic treatments compared to topical antibiotic treatment for the treatment of acute otitis externa.

METHODS

Systematic review and meta-analysis databases searched: Cochrane Library including ClinicalTrials.gov; MEDLINE; World Health Organisation International Clinical Trials Registry Platform and Web of Science to identify randomised clinical trials evaluating topical antibiotics and topical non-antibiotic agents in adults and children with acute otitis externa. Non-antibiotic therapeutics for comparison with topical antibiotics included antiseptics, steroids, non-pharmaceuticals and astringents.

RESULTS

Seventeen trials were eligible for inclusion, with 10 combined in meta-analysis. Data could be pooled comparing antiseptic and steroid monotherapies with topical antibiotic agents. There were no significant differences in cure rates in any pairwise comparisons. Individually, the majority of studies favoured topical antiseptics or steroids over antibiotics, however these differences were not significant when pooled in meta-analysis.

CONCLUSION

Antiseptic, steroid and antibiotic monotherapies are all effective for the management of acute otitis externa. There is insufficient evidence to suggest that topical antiseptic or steroid agents are superior or inferior to topical antibiotics.

Comparison of steroid antibiotic pack and 10% ichthammol glycerine pack in relieving pain of acute otitis externa in children

OBJECTIVE

This study was carried out with the objective of comparing clinical efficacy of 10% ichthammol glycerine (IG) pack with steroid-antibiotic pack for relieving pain in cases of acute otitis externa.

MATERIALS AND METHODS

A prospective quasi-randomized clinical trial was completely carried out in 65 patients at Department of ENT and Head and Neck Surgery, TU Teaching Hospital, Kathmandu. Patients of less or equal to 12 years of age and both gender presenting in our outpatient department from October 2008 to December 2009 and diagnosed to have acute otitis externa was evaluated. Six patients were excluded from the study because of not meeting the inclusion criteria. Alternately IG and steroid antibiotic packing were done. For steroid antibiotic group, we use betnovate-N, a combination of betnovate sodium phosphate 0.1% and neomycin sulphate 0.5%. Before packing was carried out, pain was assessed using Wong Baker Scale. Statistical analysis was done using "Z" test of mean to compare average number of pain score and visits in two different groups.

RESULTS

There were 33 patients in IG pack group and 32 patients in steroid antibiotic group. In less than 4 years, there were 30 children and in more than 4 years children, there were 35 children. There was male predominance in both the treatment groups and disease was most common in age group less than 4 years. There was statistical significant decrease in number of visits in steroid group in both children less than and more than 4 years. There was also significantly less pain in children with steroid antibiotic group.

CONCLUSION

Use of steroid antibiotic pack in children presenting with acute otitis externa causes earlier relief of pain as well as significantly lesser number of visits. Thus, steroid antibiotic pack is better than 10% ichthammol glycerine packs in relieving pain in acute otitis externa in children.

Interventions for acute otitis externa

BACKGROUND

Acute otitis externa is an inflammatory condition of the ear canal, with or without infection. Symptoms include ear discomfort, itchiness, discharge and impaired hearing. It is also known as 'swimmer's ear' and can usually be treated successfully with a course of ear drops.

OBJECTIVES

To assess the effectiveness of interventions for acute otitis externa.

SEARCH STRATEGY

Our search for published and unpublished trials included the Cochrane Ear, Nose and Throat Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources. The date of the most recent search was 6 January 2009.

SELECTION CRITERIA

Randomised controlled trials evaluating ear cleaning, topical medication or systemic therapy in the treatment of acute otitis externa were eligible.We excluded complicated acute otitis externa; otitis externa secondary to otitis media or chronic suppurative otitis media; chronic otitis externa; fungal otitis externa (otomycosis); eczematous otitis externa; viral otitis externa and furunculosis.

DATA COLLECTION AND ANALYSIS

Two authors assessed eligibility and quality.

MAIN RESULTS

Nineteen randomised controlled trials with a total of 3382 participants were included. Three meta-analyses were possible. The overall quality of studies was low.Topical antimicrobials containing steroids were significantly more effective than placebo drops: OR 11 (95% CI 2.00 to 60.57; one trial).In general, no clinically meaningful differences were noted in clinical cure rates between the various topical interventions reviewed. One notable exception involved a trial of high quality which showed that acetic acid was significantly less effective when compared with antibiotic/steroid drops in terms of cure rate at two and three weeks (OR 0.29 (95% CI 0.13 to 0.62) and OR 0.25 (95% CI 0.11 to 0.58) respectively).One trial of low quality comparing quinolone with non-quinolone antibiotics did not find any difference in clinical cure rate.No trials evaluated the effectiveness of ear cleaning.Only two trials evaluated steroid-only drops. One trial of low quality suggested no significant difference between steroid and antibiotic/steroid but did not report the magnitude or precision of the result. Another trial of moderate quality comparing an oral antihistamine with topical steroid against topical steroid alone found that cure rates in both groups were high and comparable (100% (15/15) and 94% (14/15) respectively at three weeks).

AUTHORS' CONCLUSIONS

There is a paucity of high quality trials evaluating interventions for acute otitis externa. The results of this systematic review are largely based on odds ratios calculated from single trials, most of which have very broad 95% confidence intervals because of small to modest sample sizes. The findings may not be wholly generalisable to primary care for a variety of reasons; only two of the 19 trials included in the review were conducted in a primary care population setting, and in 11 of the 19 trials ear cleaning formed part of the treatment (an intervention unlikely to be available in primary care). Despite these reservations, some meaningful conclusions can be drawn from the evidence available:Topical treatments alone, as distinct from systemic ones, are effective for uncomplicated acute otitis externa. In most cases the choice of topical intervention does not appear to influence the therapeutic outcome significantly. Any observed differences in efficacy were usually minor and not consistently present at each follow-up visit. Acetic acid was effective and comparable to antibiotic/steroid at week 1. However, when treatment needed to be extended beyond this point it was less effective. In addition, patient symptoms lasted two days longer in the acetic acid group compared to antibiotic/steroid.The evidence for steroid-only drops is very limited and as yet not robust enough to allow us to reach a conclusion or provide recommendations. Further investigation is needed.Given that most topical treatments are equally effective, it would appear that in most cases the preferred choice of topical treatment may be determined by other factors, such as risk of ototoxicity, risk of contact sensitivity, risk of developing resistance, availability, cost and dosing schedule. Factors such as speed of healing and pain relief are yet to be determined for many topical treatments and may also influence this decision.Patients prescribed antibiotic/steroid drops can expect their symptoms to last for approximately six days after treatment has begun. Although patients are usually treated with topical medication for seven to 10 days it is apparent that this will undertreat some patients and overtreat others. It may be more useful when prescribing ear drops to instruct patients to use them for at least a week. If they have symptoms beyond the first week they should continue the drops until their symptoms resolve (and possibly for a few days after), for a maximum of a further seven days. Patients with persisting symptoms beyond two weeks should be considered treatment failures and alternative management initiated.

A double-blind randomised clinical trial of the treatment of otitis externa using topical steroid alone versus topical steroid-antibiotic therapy

The objective of the study was to determine if the addition of topical antibiotic increases the efficacy of topical steroid in controlling otitis externa. A double-blind randomised controlled trial was performed from February 2003 to April 2005 in an otolaryngology emergency clinic (acute urban teaching hospital) in the United Kingdom. Patients were followed up for 2 weeks. Forty-five adults with otitis externa based on the presence of oedema, discharge or debris in the outer ear canal were recruited. The patients were randomised to one of the two treatment groups, namely using betamethasone sodium phosphate 0.1% (Vista-Methasone) or betamethasone sodium phosphate 0.1% with neomycin sulphate 0.5% (Vista-Methasone N), and were instructed to use the trial medication at three drops three times a day for 2 weeks. Subjects' visual analogue symptom scores (blockage, pain, discharge, and itching) for otitis externa pre-treatment (day 0) and post-treatment (day 15), percentage changes in visual analogue symptom scores as a result of treatment, proportion of patients whose symptom scores failed to improve or deteriorated on treatment were analysed. The two experimental arms demonstrated statistically similar presenting symptom scores at recruitment (mean symptom scores of 19.2 for betamethasone group and 28.7 for betamethasone-neomycin group). The mean symptom score change in response to treatment was 82.8 and 47.8% in the betamethasone-neomycin and betamethasone-alone groups, respectively. There was no statistically significant difference between the groups in median percentage symptom score change in response to treatment. All patients in the betamethasone-neomycin group showed symptom improvement but in the betamethasone alone group, five patients got worse (Fishers exact, P = 0.05). Topical antibiotic-steroid combination therapy is superior to steroid-alone treatment for symptomatic control of otitis externa.